PROSTABLOG NZ: HERE are four key issues the NZ Parliamentary inquiry into the detection and treatment of prostate cancer ought now to be focusing on:

Mass screening…or not: Not. The evidence in favour of mass screening of all middle-aged men for prostate cancer is not sufficiently strong in statistical terms to overcome the counter-arguments concerning needless and over-treatment and high likelihood of after effects that will blight quality of life.

But…it’s not strong enough yet. That may change as more studies are done and closer analysis of the large random trials is completed. PSA testing may also improve, or be replaced with something better, a test that defines the actual risk to the patient.

Guidelines to GPs must be revised. Currently, GPs are forbidden by the Ministry of Health to routinely offer PSA tests and/or rectal examinations for prostate cancer unless a man asks, or mentions symptoms. Since this can be a symptomless disease (until it’s too late), that is unacceptable. It also presumes that people don’t move around, change doctors, lose track of medical records, or simply have little idea of the implications of dad dying of prostate cancer.

If the Ministry of Health wants to avoid high-risk treatment being offered unnecessarily, it needs to move the initial gatekeeping further up the food chain to the specialists.

Specialists’ advice needs to be delivered via a more balanced and less costly method. At present, the system works well enough up to the point the pathologist finds signs of cancer in biopsy samples.

But after that, men are left to fend for themselves when it comes to seeking advice from a range of authorities. Some don’t bother, and just go with what the urologist offers. Some can’t afford the $1600 charged by a cancer specialist (oncologist), who may be the most neutral source of advice available.

In the US, the first specialists in the hierarchy, urologists, earned themselves the unenviable moniker of “prostate snatchers” because of the lucrative, medical insurance-backed business of prostate surgery.

The public needs to be kept up to date – in layman’s terms – with diagnostic and treatment developments. This is not happening at present. The Ministry and its satellite committees do not have readily available, up-to-date information on the web to help men with newly diagnosed prostate cancer become fully informed before making one of the biggest decisions of their lives.

As wealthy male baby boomers hit the danger zone, enormous amounts of US, European and Asian money are going into researching and developing new drugs, methods of surgery and radiation, diagnostic tools and a bewildering range of related methdologies.

That’s the point – it’s bewildering to the average Kiwi, who must hope his medics are keeping up to date and that the government is adequately funding new treatments.

For example, there is Provenge, a new $100,000+ drug regime that will extend life for a few months, and which is now selling big in the US. When will we see it here?

Communicating the relevance of the overseas prostate industry boom to Kiwis cannot be left solely to the news media here: that’s worse than leaving it to chance and the public relations industry.

Few, if any, journalists in NZ take an abiding interest in prostate cancer (why would they – it’s one of many diseases), and what they do write is sometimes ill-informed, incomplete, inaccurate and out of date.

Finally, the Health Select Committee would be wise to keep its files open on this inquiry. It would be a mistake to shut the doors on a tsunami of prostate cancer information that emerges daily on the web.

Developments are moving so quickly, the committee should require the Ministry of Health to report regularly about what’s happening. The inquiry report, when it finally emerges, should be an interim one that can be updated over time.

This document made it clear that the group – an independent incorporated society originally set up by the government in 1996 – is opposed to population-based PSA screening.

To save one life, up to 41 men could incur significant harm.

It bases this view on its assessment of numerous NZ and international studies, including two large randomised trials (one European, the other American) that were reported last year.

Here are some of the last pages of the group’s December, 2009, submission (RCT = random controlled trial):

This also appears to be the main thrust of submissions on PSA testing from other health authorities (although the Guidelines Group is at pains to stress it is independent from the Ministry of Health).

Another “official” organisation, the National Health Committee, said in its submission (August 26, 2009) that it has seen nothing to change its 2005 advice to the MOH that population-based PSA screening is not an acceptable option.

However, it did favour targeted screening of high-risk groups, such as men with a family history of prostate cancer.

The NHC is aware that since providing its advice in 2005, clinical practice has found
that targeted screening for men at high risk of prostate cancer appears to be useful
and potentially cost effective. These are men who have a family history of prostate
or related cancers.

It did make a couple of pleas, however, calling for up-to-date information to hand out to patients, and for treatment to be available to all:

It is important that inequities in access relating to follow up after positive
screening results, and for symptomatic men, are identified and eliminated.

The Cancer Society agreed with the Guidelines Group, and backed this up by quoting from selected organisations in other Western countries.

Most agencies around the world have some form of recommendation that decisions for screening for prostate cancer should be made on an individual basis and in consultation with a medical professional:

The Australian Cancer Council states that:
“In the absence of direct evidence showing a clear benefit of population based screening for prostate cancer, a patient centred approach for individual decisions about testing is recommended. Screening discussions and decisions should always include and take into account, age and other individual risk
factors such as a family history of the disease” (Cancer Council Au 2005).

The American Cancer Society states that:
“The American Cancer Society (ACS) does not recommend routine testing for prostate cancer at this time. ACS believes that doctors should discuss the pros and cons of testing with men so each man can decide if testing is right for him. If a man chooses to be tested, the tests should include a PSA blood test and
DRE (digital rectal exam) yearly, beginning at age 50, for men at average risk who can be expected to live at least 10 more years.” (American Cancer Society 2009).

The UK Cancer Research Council states:
“in the UK, there is no national screening programme for prostate cancer because trials have not yet shown clear evidence that screening will reduce deaths from this disease. Also, many men diagnosed with
prostate cancer have very slowly growing cancers that will never cause any symptoms or problems in their lifetime. So at the moment there is no clear benefit in diagnosing prostate cancer early and it may actually cause harm for some men.”(Cancer Research UK 2009).

Urological Society of Australia and New Zealandstates:
“Individual men aged 50 to 70 years with at least a 10 year life expectancy should be able to be screened by annual DRE and PSA testing, after appropriate counselling regarding the potential risks and benefits of investigations and the controversies of treatment.”(Urological Society ANZ 1999).

The majority of submissions – from prominent medical practitioners, prostate cancer lobby groups and patients – urged the committee to recommend PSA testing, if not on a population (all men) screening basis, then at least as a service offered routinely by GPs, without men having to ask (the current MOH policy).

PROSTABLOG: When can we expect a report from the NZ parliamentary inquiry into the early detection and treatment of prostate cancer, which was launched a little over a year ago?

No word on that from the committee, but perhaps two of the most powerful “words” in the debate on screening were submitted to the committee just before last Christmas (unreported in the news media, so far as I can tell).

They came from eminent pro-screening urologist Robin Smart and from the Ministry of Health’s expert panel, the NZ Guidelines Group, which has been strongly anti-screening (population-based).

The conclusion is that it is now very difficult if not impossible to conduct trials of controls having no testing versus screened having PSA/DRE (PSA tests/digital rectal examinations) testing with endpoints of death or metastases in advanced countries especially the United States.

This is largely due to the international improvements in these aspects because of PSA/DRE testing and consequent reluctance of men to remain in control groups.

This in turn means that it is going to continue to be difficult for authorities and governments responsible for making decisions concerning setting up national prostate cancer screening programmes who are waiting for more information before doing so.

These decisions will have to be made largely on current information from existing trials, studies and experience…

The weight of evidence in favour of PSA/DRE testing is now irrefutable after almost two decades of international experience.

To go back to the time before PSA testing would now be unthinkable.

Of course we hope for the perfect tests, perfect treatment and continue to look for improvements. But men today need the benefit of current technology which the evidence shows is saving between a third to a half of those who would otherwise die of prostate cancer where it is applied.

In its final submission (dated the same day as Smart’s, December 16), the guidelines group gave a contrary view.

It looked at nearly 10,000 research abstracts and chose 166 it says were relevant to the brief given to it by the Ministry of Health.

Its analysis concluded that the potential harm from population-based screening outweighs benefits.

The best case scenario it could find estimated that a screening programme conducted on all men aged 50 to 74 for nine years would save about 40 lives a year (from the 600 who die from the disease in NZ each year).

Those 360 lives saved over nearly a decade had to be weighed against the following “harm” that could be done:

An estimated 41 men would suffer significant treatment complications for every one life saved.

Of the additional 1953 men per year requiring prostate cancer treatment (presumably on top of the 2500 now), 43% to 88% would have sexual dysfunction, 10% to 35% urinary dysfunction and 8% to 43% bowel dysfunction (the range depending on whose research is consulted)

Each year, there would be the following additional complications – 838 to 1677 cases of sexual dysfunction; 156 to 838 cases of bowel dysfunction; and 195 to 682 cases of urinary dysfunction.

Meantime, international debate on screening continues.

HERE> is a report on a pro v con panel discussion at the recent American Urological Association annual conference.

And, Mike Scott, sitemaster of the New Prostate Cancer Info-Link in the US, says he agrees with an April article in the Australian Medical Journal that said population-based screening (that is, screening of all men) cannot be sanctioned until something more accurate than the PSA test is developed. READ MORE>

PROSTABLOG NZ: The ideological debate about prostate cancer screening hasn’t moved along much in New Zealand over the past few years.

I’m judging this from an anecdote a guest speaker at my journalism course told students this week.

An experienced journalist, she said a few years ago she was writing a piece for NZ Listener magazine about PSA screening, and the Ministry of Health would speak to her only on the condition they got to see the resulting article prior to publication.

That usually causes journalists to feel apprehensive, and in this case her fears were realised.

The Ministry people hit the roof over what she wrote (basically, that all men over 50 should be urged to get PSA tests), and made this plain to her editor.

Judging by what I heard from the Ministry team at the Health Select Committee hearing into prostate cancer screening late last year, the official view is still the same: PSA bad.

Speaking of which – I wonder when we’re going to hear anything further from the committee?

Chairman Paul Hutchison made the MOH people promise to deliver their final views last November.

PROSTABLOG NZ: This is a very special post – the one thousandth for Prostablog since we launched on April 1, 2009.

It’s special because I’ve reserved it for a brave and resilient couple, Kim and Brian, whose saga with prostate cancer brought tears to the eyes of every person in the Select Committee room at the NZ Parliamentary inquiry into prostate cancer this week.

I’ve never met Kim Cook. We’ve spoken on the phone just a couple of times.

But I know a lot about her from the way she has written for Prostablog over the past winter months.

Her story (entitled John and Mary’s story) is about the struggle she and partner Brian have faced getting treatment for his cancer, which is now advanced.

Kim said she wanted something to come out of their battle: how could she get her message across about the frustrations some prostate patients face with the medical system in NZ?

What better way than to tell the story to the Health Select Committee on the first day of its hearings.

They had already had about 10,000 words from her in a written submission.

What came on Wednesday, via phone teleconference (because Brian was not up to the trip from Auckland to Wellington), was a gritty, emotional but devastatingly precise introduction to their story.

Kim’s voice broke only once, near the end, when she talked of crying herself to sleep most nights.

MPs, reporters, audience, dabbed their eyes at this point.

It was important for the MPs on the committee to hear from this brave woman.

It was a reality check for them, a respite from the mostly dispassionate testimony of medics and bureaucrats.